Synopsis In order to relieve the pilot who had been on duty from Les Escoumins, Quebec, aboard the NAVIOS MINERVA, the pilot boat NAVIMAR V came alongside the bulk carrier while passing the pilot station at Qubec, Quebec, shortly before 0100. Two pilots from the Qubec / Trois-Rivires sector climbed onto the accommodation ladder, but before they could reach the vessel's deck, the pilot boat plunged into the sea and resurfaced upside down. The master of the pilot boat was trapped in a compartment and the deckhand was thrown overboard. The Canadian Coast Guard Ship STERNE, which was dispatched to the scene, recovered the deck-hand, who had climbed onto the overturned hull, and the master, who had swum to the surface. The STERNE took the survivors to the Canadian Coast Guard base, where an ambulance was waiting to take them to hospital. Both crew members were suffering from hypothermia and nervous shock, but they were released from hospital a few hours later. The NAVIMAR V drifted in the St. Lawrence River before sinking off the mouth of the Saint-Charles River, in about 30 metres of water. The pollution caused by the pilot boat was deemed minor. The Board determined that the pilot boat NAVIMAR V overturned because when she came alongside the NAVIOS MINERVA, she overtook a wave generated by the ship, pitched onto the wave crest then surged down into the trough of the next wave before plunging into the sea. The submerged bow slowed down the pilot boat but, due to her momentum, she continued to pitch until the vessel turned over. The decision to use the accommodation ladder instead of the vessel's pilot ladder contributed to the sequence of events. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the NAVIMAR V The pilot boat, built entirely of aluminium, has a hard-chine hull and a spray deflector on each side of the bow. There are two compartments under the after deck, each accessible through a hatch. Aft are fuel tanks and the steering gear which controls two rudders; midships are two engines driving the two screws. On the after embarkation deck, two guardrails have been installed on each side of the centre line, about 70 cm apart, so that pilots can hold the handrail during transfer manoeuvres. The superstructure extends forward from amidships to the chain locker bulkhead. A glazed double door and a companionway aft of the passenger compartment provide access to the after deck. 1.1.2 Description of the NAVIOS MINERVA The NAVIOS MINERVA is a Panamanian-registered bulk carrier built in Japan in 1997, which is 225 m long and has a deadweight of 68 775 tonnes. The bridge, accommodation and engine-room are aft of the seven cargo holds. On each side of the accommodation there is an accommodation ladder that lowers forward. The vessel is also equipped with a dedicated facility for pilot transfers, on each side of the vessel, near hatches Nos. 5 and 6. 1.2 History of the Voyage On 06 August 1997, the NAVIOS MINERVA, carrying 22 crew members and a cargo of 50 968 tonnes of alumina from Cape Town, South Africa, was upbound in the St. Lawrence River en route to the port of Trois-Rivires, Quebec. At 1414 eastern daylight time (EDT)[3], at calling-in point 4A, the Marine Communications and Traffic Services (MCTS) traffic regulating officer at Les Escoumins instructed the NAVIOS MINERVA to prepare the starboard accommodation ladder for the pilot to embark. At 1508 at calling-in point 5A, the MCTS traffic regulating officer asked the NAVIOS MINERVA to approach within half a nautical mile of the Les Escoumins pilot station, and he reminded navigating personnel to use the starboard accommodation ladder. At 1534, a pilot from the Les Escoumins/Qubec sector boarded the vessel using the accommodation ladder, and the vessel proceeded to the port of Qubec without incident. At 2355 off Sainte-Ptronille, Quebec, the pilot reported to the Qubec MCTS, and the vessel approached the Qubec pilot station. On 07 August 1997 at 0005, main engine speed was reduced to full manoeuvring speed ahead, and two minutes later to half speed ahead. In the meantime in Louise Basin, two relief pilots from the Qubec/Trois-Rivires sector boarded the NAVIMARV and sat down in the passenger compartment. The pilot boat left the pilot station, entered the St. Lawrence River, travelled along the wharves to the mouth of the Saint-Charles River, then made a half-turn offshore to meet the NAVIOS MINERVA. Off Louise Basin, the pilot boat overtook the bulk carrier on her starboard side. Using both engines and a searchlight, the master manoeuvred the pilot boat so as to come alongside the vessel at a point about 15 m forward of the accommodation ladder. The Doppler log of the NAVIOS MINERVA indicated a speed over the ground of eight knots. The master of the pilot boat rested the port shoulder of his boat against the bulk carrier's side. The deck-hand on the pilot boat instructed the vessel's crew to lower the accommodation ladder. By reducing the speed of the port engine, the master of the NAVIMARV allowed the vessel to catch up to the pilot boat until the accommodation ladder was over the after deck of the pilot boat. He noted that the guardrails in the middle of the after deck were in the way, and ordered the deck-hand to ask that the accommodation ladder not be lowered any further. The master moved the stern of the pilot boat away from the bulk carrier's side, and then the accommodation ladder was lowered to within 30 cm of the after deck. The two relief pilots immediately began climbing the accommodation ladder. A few moments later, the stern of the pilot boat raised suddenly and a slight list developed to starboard as the bow plunged into a wave trough. On the after deck, the deck-hand noticed that the bottom platform of the accommodation ladder was slowly moving toward the superstructure of the pilot boat. The master immediately ordered the deck-hand to have the accommodation ladder raised and the bulk carrier's crew did so at once. On turning forward, the master noted that the bow had plunged deeply into the water. The water level was now up to the top of the forward wheel-house windows. He moved the controls for both engines to the neutral position and tried to exit the accommodation but the after door was now above his head. When the bottom platform of the accommodation ladder struck the port ventilation trunk, the deck-hand toppled overboard. The pilot boat continued her forward pitching motion and, at about 0010, resurfaced upside down. In the water, the master was disoriented in the darkness under the completely overturned hull. He saw light which he thought was coming from the surface and swam in that direction, but found himself in the engine compartment. In the meantime the deck-hand, who was wearing a flotation device, surfaced near the hull. One of the two relief pilots hurried to the bulk carrier's bridge to inform the bridge team of the situation. At 0012, he reported the accident to the Qubec MCTS centre. The speed of the bulk carrier's main engine was reduced to slow ahead, and at 0013, the engine was stopped. The MCTS relayed the information to the Qubec Search and Rescue (SAR) Sub-Centre, and at 0014, the CCGS STERNE was dispatched to the scene of the accident, off berth No. 25. The MCTS also contacted the local tug firm, which mobilized the tug DONALD P.. In the meantime, the deck-hand climbed onto the overturned hull and made verbal contact with the master, who was trapped in the engine compartment. Using searchlights, the crew of the STERNE located the hull of the NAVIMARV at about 0023, and recovered the deck-hand. When the DONALD P. reached the scene at about 0030, a davit was prepared to attempt to right the pilot boat. Twice the master tried to swim to the surface, but since he was disoriented in the darkness, he returned to the engine compartment instead. At about 0042, air bubbles were seen coming from the openings of the pilot boat, which began to right herself. The master took advantage of the situation to swim to the surface, where he was recovered by the crew of the STERNE. The SAR unit returned to the Canadian Coast Guard (CCG) base, where an ambulance was waiting for the survivors. Both crew members were suffering from hypothermia and nervous shock, but were released from hospital a few hours later. At 0050, the DONALD P., which had remained at the scene, reported to the Qubec MCTS that the pilot boat was sinking in 30 m of water off the mouth of the Saint-Charles River. She was refloated on 16 September 1997. 1.3 Injuries to Persons 1.4 Damage 1.4.1 Damage to the Pilot Boat The windows in the superstructure were shattered; water destroyed the navigation instruments and the electrical and electronic installations as well as the insulation. Damage included deformation of the rudder stocks, detachment from the hull of a section of the spray deflector, and abrasion damage to the port side ventilation trunk. However, it was possible to restart both engines when the boat was refloated. 1.4.2 Damage to the Vessel Damage was limited to the bottom platform of the starboard accommodation ladder of the NAVIOS MINERVA, which was deformed when it struck the port side ventilation trunk of the NAVIMARV. 1.4.3 Damage to the Environment It was reported that very little oil leaked from the pilot boat. The diesel fuel remained in the fuel tanks. 1.5 Certification 1.5.1 Pilot Boat and Vessel The NAVIMARV and the NAVIOS MINERVA were crewed, certified, and equipped in accordance with existing regulations. 1.5.2 Personnel The master of the NAVIMARV is certificated for the command of a vessel used in pilotage services in Minor Waters, Class II. The master and watch officers of the NAVIOS MINERVA are certificated for the class of their vessel and for the type of voyage. 1.5.3 Pilot The pilot aboard the NAVIOS MINERVA holds a pilot licence valid for the tonnage of the vessel he was piloting and for the sector of the St. Lawrence River in which he was working. 1.6 Personnel History 1.6.1 Master of the Pilot Boat The master of the pilot boat had 46 years' navigating experience and had been the master of the NAVIMARV since 1989. Since that time he had carried out over 4000 pilot transfer assignments. The evening before the occurrence he had gone to bed at about 1900 and had risen at about 0700 on 07 August 1997. He had consumed one alcoholic beverage at mid-day, and then he had reported for work at the pilot station at about 1815. 1.6.2 Master of the Vessel The master had been navigating for 18 years and had served as master of the NAVIOS MINERVA since 30 March 1997. 1.6.3 Pilot The pilot had 43 years' navigating experience and had been serving as a pilot since 1966. As the bulk carrier was a new vessel, this was the pilot's first assignment on the NAVIOS MINERVA. 1.7 Weather Conditions and Current Information 1.7.1 Weather Forecasts In the port of Qubec on 07 August 1997, the weather was clear, the winds light, and the sea calm. 1.7.2 Tide Forecasts The accident occurred at about 0010 on 07 August 1997, or about 2 hours and 40 minutes after the forecast high tide; therefore, both vessels were in an ebb current at the time of the transfer. 1.7.3 Current Forecasts According to the Fisheries and Oceans Canada publication Atlas of Tidal Currents, two to three hours after high tide at Qubec, the current vector off Louise Basin indicates a speed of three to four knots and a direction of approximately 060T. Those parameters are based on average weather conditions. 1.8 Navigation 1.8.1 Navigation Instruments The navigation instruments of both vessels were in good working order. 1.8.2 Pilotage Since visibility was good, conduct of both the vessel and the pilot boat was carried out by visual observation during the approach of the two vessels and the transfer of the pilots. 1.9 Communications 1.9.1 Communications Between the Vessel and the MCTS Centre On 06 August 1997 at 1414, the NAVIOS MINERVA reported at the calling-in point off Pointe--Michel, Quebec. The Les Escoumins MCTS centre then instructed the crew to prepare the starboard accommodation ladder for the pilot. At 1508, when the navigating personnel reported at the next calling-in point, off Pointe-au-Boisvert, Quebec, the MCTS traffic regulating officer asked for confirmation that the starboard accommodation ladder was ready, and asked the vessel to proceed to the Les Escoumins pilot station, five cables from shore. The bulk carrier subsequently proceeded up the St. Lawrence River to the port of Qubec with no communication problems. Following the accident at 0012:12, one of the relief pilots from the Qubec/Trois-Rivires sector reported the occurrence to the Qubec MCTS Centre while the NAVIOS MINERVA was proceeding at reduced speed in the port of Qubec. 1.9.2 Communications Between the Vessel and the Pilot Boat A replay of the very high frequency (VHF) radio communication tapes from 0000:01 on 07 August 1997 confirmed that there had been no communication between the NAVIMARV and the NAVIOS MINERVA. Since neither the master of the pilot boat nor the pilot on board the bulk carrier was expecting any problems with the transfer manoeuvre, they did not see any point in making contact by radiotelephone to determine when the pilot boat should come alongside and transfer the pilots, nor were they required to do so by regulations. 1.9.3 Communications Between the Pilot and the Navigating Personnel There was no misinterpretation of the helm or speed orders for the manoeuvres on board the NAVIOS MINERVA. 1.10 Pilot Boat NAVIMARV 1.10.1 Modification History The pilot boat was purchased in 1988 to be used in pilotage services in the port of Qubec. Previously this vessel had been used as a service boat in the Vancouver area. During the winter of 1993, the superstructure was shortened in order to enlarge the after deck and the exhaust system of the main engines was converted to a wet system. In 1996 further modifications were made to improve transverse stability and to correct a bow-trimming condition. At that time, the hull was widened from 3.05 to 3.76 m, and the original engine was replaced with two 210 hp units mounted lower and farther aft. The fuel tanks were moved aft. The volume of the bow was increased and a spray deflector added. An incident occurred in the spring of 1997, when a strong easterly wind stirred up a moderate sea off Sainte-Ptronille. While the pilot boat was proceeding to an upbound vessel for a pilot transfer, she suddenly plunged her bow into the sea. The master reduced the engines' speed and the forward end of the pilot boat resurfaced. A second approach was then made without incident. Following that incident, the owner had approximately 800 kg of concrete ballast added to the stern of the boat, near the steering gear. It was reported that adding the ballast improved but did not completely eliminate the boat's unsatisfactory dynamic trimming behaviour. The addition of solid ballast was not reported to Transport Canada as required. 1.10.2 Pilot Boat Selection Criteria Every five years, the Laurentian Pilotage Authority (LPA) issues a call for tenders for pilot boat services in the ports of Qubec and Trois-Rivires. Bidders must comply with specifications set by the LPA. The selection criteria include construction materials, length and breadth of the hull, type of propulsion and speed, power-generating system, navigation instruments and passenger-carrying capacity. The LPA's requirements are based on the Standards for Pilot Vessels, TP 10531, issued by Transport Canada in 1989, which deal only superficially with the ergonomics of the wheel-house and the location and number of embarkation/disembarkation decks. References concerning the field of view from the steering station and the stability requirements are brief. 1.10.3 Regulatory Inspection Requirements Since most pilot boats are also passenger vessels that carry few passengers and are of small tonnage, the regulations governing the tonnage and class of voyage for these vessels are those that apply to passenger vessels that carry 12 passengers or less, and are not specific to pilotage services per se. These small boats tend to plane at full speed, but the regulatory requirements of STAB 6 of the Stability, Subdivision and Load Line Standards, TP 7301, do not address characteristics that could affect longitudinal dynamic behaviour. The NAVIMARV was not required to have a stability booklet. Transport Canada called for initial statical stability data for the vessel after the 1996 modifications and waived the requirement for an inclining experiment for certification purposes. Since the vessel was considered a pilot boat and a passenger vessel, she was issued an inspection certificate limited to Minor Waters Class II voyages as a pilot boat. 1.10.4 Crew This pilot boat is operated on a 24-hour basis by four crews, each comprising a master and a deck-hand. Among them, these crews account for some 3500 transfers per year. 1.10.5 Visibility from the Steering Station The after deck serves as the embarkation/disembarkation deck and the wheel-house is at the forward end of the superstructure. At the time of the occurrence, the master's view aft from the steering station was partly obstructed by the passenger compartment. In the moments before the occurrence, the master's attention was focussed on transferring the two pilots to the bulk carrier, and according to the crew, there was no fore-warning of the impending accident. 1.11 Vessel NAVIOS MINERVA 1.11.1 Accommodation Ladder On each of the vessel's quarters, there is a 12.1 m-long accommodation ladder. Each ladder is fastened to a pivoting platform approximately halfway between the transom and the forward end of the accommodation. At that point, the vessel's side is curved. The accommodation ladder on each side of the vessel lowers forward and the ladder's bottom platform does not rest against the vessel's side, but juts out more than a metre from the shell plating. 1.11.2 Pilot Ladder In compliance with international regulations, the vessel is also equipped with a dedicated facility for pilot transfers, on each side of the vessel near hatches Nos. 5 and 6. Because the vessel may have a high freeboard when in light condition, the facility consists of a combination accommodation-type ladder and pilot ladder. This combination of ladders enables the pilot to climb three to nine metres up a rope ladder above the pilot boat before switching ladders and climbing the steps of the second ladder. 1.11.3 Visibility from the Bridge Although a pilot boat manoeuvring alongside cannot be seen by a person from the centre window of the bridge, it is possible to get a good view of the pilot boat from the bridge wing. 1.11.4 Manoeuvring Speeds Bridge orders are relayed to the engine-room via an engine telegraph. When the vessel is loaded, the manoeuvring speeds correspond to the following speeds: Depending on the amount of cargo being carried, the navigating personnel estimate full speed ahead (sea) to be approximately 12.5 knots. 1.11.5 Main Engine Data Recorder A check of the timer for the main engine data recorder showed that the time recorded was the exact local time and that the time zone was the one in effect. The recorded data indicated the following changes of speed: 1.12 Pilotage Services 1.12.1 Use of the Pilot Ladder The Regulations Respecting Pilot Ladders and Mechanical Pilot Hoists on Ships made pursuant to the Canada Shipping Act did not apply to the Panamanian-registered NAVIOS MINERVA because the Canadian regulations only apply to Canadian vessels. The Administration responsible for the vessel, Panama, is a signatory to the 1974 International Convention for the Safety of Life at Sea (SOLAS). Chapter 5, Rule 17 of the SOLAS Convention stipulates that pilot ladders must be used for pilotage service. The International Maritime Pilots Association also advocates the use of pilot ladders. The same is true of the annual edition of Notices to Mariners,which is published by Fisheries and Oceans Canada and which is required to be carried on all ships in waters of Canadian jurisdiction. This document contains a notice to foreign mariners calling on them to comply with the requirements of the SOLAS Convention. The NAVIOS MINERVA had a draught of 10.85 m and and a freeboard of about 7.45 m. Since the bulk carrier's freeboard was less than 9 m, pilots could readily climb on board using the pilot ladder facility rather than using an accommodation ladder. 1.12.2 Use of the Accommodation Ladder In the compulsory pilotage areas on the St. Lawrence River, most pilots use the accommodation ladder for access to vessels. This pilot transfer arrangement practice dates back a number of decades, to a time when most vessels were designed with the accommodation amidships. Thus the pilots requested that the MCTS centre inform foreign crews of this particular practice when they report at the two calling-in points downstream of the Les Escoumins pilot station. In this instance, the combination of ladders intended for pilot transfer located amidships was not used because the MCTS centre had instructed the bulk carrier's crew to prepare the starboard accommodation ladder. The navigating personnel did not inform the MCTS centre that the vessel was also equipped with a pilot embarkation/disembarkation facility amidships. 1.12.3 Speed of the Vessels During the Transfer The movements of the NAVIMARV and the NAVIOS MINERVA in the port of Qubec were recorded on a radar video plotter at the Qubec MCTS centre. It was therefore possible to determine the approximate speed of both vessels during the approach manoeuvre and the transfer of the two pilots. Between 0006:08 and 0010:56, the NAVIOS MINERVA moved approximately 0.64 nautical mile, indicating a speed over the ground of eight knots. The video plotter's automatic radar plotting aid (ARPA) system helped determine the drift of the tug DONALD P. alongside the NAVIMARV after the accident; it indicates a movement in the direction 031T at a speed of 1.9 knots. Thus in an ebb tide, the pilot transfer was made at a speed through the water of about 9.9 knots. Speed and heading have a greater effect on the behaviour of a small vessel than a large ship in similar seas. A small vessel running before the sea does not progress at a uniform rate, but is subject to some acceleration and deceleration when on the crest or in the trough of the waves. Should the small vessel lose synchronization with the waves, its smaller mass, and inertia can cause significant changes of its speed between wave crests. Consequently, the forward rate of progress of a small vessel fluctuates much more than a larger vessel, in similar conditions and at similar speeds. 1.12.4 Safety Management System Although the owner of the pilot boat was not required to comply with the International Safety Management Code adopted by the International Maritime Organization (IMO), he had introduced a safety management system on board his pilot boats. The company's code of practice for pilot transfers is based on the code prepared by the British Ports Federation. Article 3.1 of the company code stipulates that the master of the pilot boat must choose where the transfer is to be made, in conjunction with the pilot of the vessel to the extent possible. Chapter 4 of the code lists the steps to be followed during the approach, including making contact with the vessel by VHF radiotelephone to exchange the information required for a safe transfer. Canadian regulations contain no standards or code of practice for pilot transfer arrangements.